Page 136 nursing.elitecme.com Complete Your CE Test Online - Click Here chart annotation consistent with all elements of sepsis or septic shock ascertained through chart review. EBP alert! Serum lactate levels are measured in the first 3 hours of presentation. Higher serum lactate levels are associated with an increase in mortality, helping to identify patients at risk for a poor outcome (Mikkelsen et al., 2009). Six-hour bundle (to be completed within six hours). ● ● Administer vasopressors for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure (MAP) ≥ 65 mmHg. ● ● In the event of persistent hypotension after initial fluid administration (mean arterial pressure (MAP) < 65 mmHg) or if initial lactate was ≥ 4 mmol/L, reassess volume status and tissue perfusion and document findings. ● ● Remeasure lactate if initial lactate is elevated. Document reassessment of volume status and tissue perfusion with either repeat focused exam (after initial fluid resuscitation), including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings, or two of the following: ○ ○ Measure central venous pressure (CVP). ○ ○ Measure ScvO2. ○ ○ Bedside cardiovascular ultrasound. ○ ○ Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge. Nursing consideration: Nurses can go to http://www.sccm.org/ SiteCollectionDocuments/SSCBundleCard_Web.pdf to print out bundle badge cards for quick and easy reference of bundle recommendations. Self-evaluation: Question 5 Which of the following is part of the 3-hour bundle that should be completed within the first 3 hours of presentation of sepsis? a. Ensure airway and oxygenation. b. Measure lactate levels. c. Perform diagnostic imaging to determine source of infection. d. Secure venous access. CAUSATIVE AGENTS The causative agents behind sepsis are numerous and include bacterial, fungal, and viral agents and parasites. However, bacterial agents that induce infection are the most common culprit (Neviere, 2017). In almost half of all reported cases of sepsis, a pathogen is not identified (Gupta et al., 2016). Respiratory infections, such as pneumonia, are the most frequent cause of sepsis and septic shock, followed by intraabdominal infections, urinary tract infections, and primary bloodstream infections (Artero et al., 2012). Respiratory and abdominal infections have a poorer prognosis than sepsis that is caused by other factors (Artero et al., 2012). When sepsis is caused by gram-negative bacteria, the outer membrane component that triggers sepsis can be an endotoxin, lipopolysaccharide, or lipid A (LaRosa, 2010). Escherichia coli, salmonella, shigella, pseudomonas, acinetobacter, neisseria, haemophilus influenza, and vibrio cholera are types of gram-negative bacteria. Gram-positive bacteria include staphylococcus, streptococcus, and enterococcus. Gram-positive bacteria produce exotoxins, which are much more potent than the endotoxins produced by gram-negative bacteria and can be implicated in toxic shock syndrome caused by staphylococcus aureus or streptococcus pyogenes (Cohen, 2012). These bacteria cause T cell activation and trigger the release of proinflammatory lymphokines (Cohen, 2012). Toxic shock syndrome can affect otherwise healthy people. Mortality rates can be as high as 50% (Cohen, 2012). Gram-negative bacteria were historically noted as the most common type of bacteria associated with the development of sepsis. However, gram-positive bacterial infections are increasing in incidence, and studies have shown gram-positive bacteria to be an even greater source for sepsis than gram-negative bacteria are (Martin, Mannino, Eaton, & Moss, 2003). The most common organisms that lead to the development of sepsis are staphylococcus aureus, pseudomonas, enterobacteriaceae (escherichia coli is the most common of this species), fungi, and Acinetobacter (Mayr, Yende, Angus, 2014). In addition, the incidence of multiresistant bacteria (multiresistant pseudomonas, methicillin-resistant staphylococcus) has increased significantly over recent years (Artero et al., 2012). Nurses may have the opportunity to review the culture reports on patients long before the clinician and are, therefore, in a position to recognize the reports that need immediate reporting. Starting the correct antibiotic may be instrumental in avoiding septic shock. Table 1. Frequency of pathogens associated with the development of sepsis Gram Positive Gram Negative Viruses Fungus Parasites Methicillin-susceptible Staphylococcus: 14%–24% Escherichia coli: 9%–27% 2%–4% Candida albicans: 1%–3% 1%–3% Methicillin-resistant Staphylococcus: 5%–11% Pseudomonas aeruginosa: 8%–15% Streptococcus pneumoniae: 9%–12% Klebsiella pneumoniae: 2%–7% Enterococcus: 3%–13% Haemophilus influenzae: 2%–10% Annane et al., 2005 Viral infections Viral infections include influenza, parainfluenza, meningitis, pneumonia, respiratory syncytial virus, HIV, herpes, Epstein-Barr virus, Cytomegalovirus, and Adenovirus (Pomerantz & Weiss, 2016; Sepsis Alliance, n.d.). Viral infections can cause sepsis directly or ultimately lead to the development of a bacterial infection (e.g., a person starts with influenza that leads to the development of a bacterial pneumonia). Sepsis from a viral infection can occur in patients with compromised immune function and who are highly susceptible to opportunistic pathogens. Fungal infections The incidence of fungal infections as a cause for the development of sepsis has increased greatly in recent years (Martin et al., 2003). The reason for this increase could be better management and treatment of bacterial infections or a rise in nosocomial-associated fungal infections